Product Details

Author Information

Corresponding Author
Floribella Redondo
Campesinos Sin Fronteras
725 W. Main St.
Somerton, AZ 85350
United States
p: 520 627 1060
floribella@campesinossinfronteras.org

Authors (listed in order of authorship):
Emma Torres
Campesinos Sin Fronteras

Idolina Castro
Campesinos Sin Fronteras

Angelica Villasenor
Campesinos Sin Fronteras

Maia Ingram
University of Arizona College of Public Health

Product Description and Application Narrative Submitted by Corresponding Author

What general topics does your product address?

Public Health

What specific topics does your product address?

Diabetes

Does your product focus on a specific population(s)?

Latino/Hispanic, Rural, Seniors

What methodological approaches were used in the development of your product, or are discussed in your product?

Community-academic partnership, Community-based participatory research , Interview

What resource type(s) best describe(s) your product?

Manual/how to guide

Application Narrative

1. Please provide a 1600 character abstract describing your product, its intended use and the audiences for which it would be appropriate.*

Diabetes is a devastating disease and disproportionately impacts ethnic minorities in death and illness related to this disease. Culturally responsive diabetes education and support programs are not available in many communities. The Promotora Community Health Manual: Developing a Community-Based Diabetes Self Management Program provides a conceptual framework for designing or refining a program of community support for diabetes self management. This guide was developed primarily by and for community health workers, known as promotores/as in Mexican American communities, but is also a useful tool for supervisors and program managers in both community-based and clinical settings. The overall objectives of the manual are: 1) to provide a general orientation to the philosophy and preparation of promotores/as or community health workers; 2) to explore aspects of diabetes self management that may not be addressed in clinical care such as managing stress and depression, the inclusion of the family in promoting self management, and the role of spirituality in caring for diabetes; 3) to provide promotores/as and programs with practical strategies, tools, and suggestions that will assist them in working effectively with their community; and 4) to consider programmatic aspects of a clinical versus a grassroots program for a promotor/a diabetes self management program.

2. What are the goals of the product?

The purpose of this manual is to serve as a guide and support to community health workers, or promotores/as de salud, their supervisors, and their organizations in creating or refining a community-based diabetes self-management program. To this end, the manual is a compilation of experiences, testimonies, and tools from nine promotoras engaged in designing and sustaining a program of community support to farmworkers and their families in an Arizona-Mexico border community. The Campesinos Diabetes Management Program, originally funded by the Robert Wood Johnson Diabetes Initiative, continues to respond to the needs of the community in addressing the devastating impact of diabetes. While this manual was designed within the context of a Latino, migrant community on the U.S.-Mexico border, we believe that the lessons learned are relevant to diverse communities and programs.

The objectives of this manual are:

1)To provide a general orientation to the philosophy and preparation of promotores/as dedicated to providing diabetes education and support services to their communities.
2)To explore specific aspects of diabetes self management that may not be addressed in clinical care such as: managing stress and depression, the inclusion of the family in promoting self management, and the role of spirituality in caring for diabetes.
3)To provide promotores/as and programs with practical strategies, tools, and suggestions that will assist them in working effectively with their community.
4)To consider programmatic aspects of a clinical versus a grassroots setting for a Promotor/a Diabetes Self-Management Program.

3. Who are the intended audiences or expected users of the product?

? Promotores/as also known as community health promoters, community health workers, lay health workers, community health representatives, and community health advocates, as well as others who offer their services to their community. This manual will be useful to novice promotores/as in recognizing and taking pride in the unique gifts they bring to their work. The manual will also serve experienced promotores/as who may benefit from our experience in addressing the severe physical and emotional impact of diabetes, not only on those with diabetes, but on members of their families and the community as a whole.

? Those responsible for supervising promotores/as and developing promotor/a programs.

? Those responsible for designing and running programs with a health social service, or community focus.

? Other people and groups with an interest in the Promotor(a) Model.

4. Please provide any special instructions for successful use of the product, if necessary. If your product has been previously published, please provide the appropriate citation below.

This manual is not designed to be a comprehensive source of information about diabetes self care for promotores/as. Rather, the goal is to share our experience with promotores/as and those who work with promotores/as to inform the development of their own programs. We also hope to motivate promotores/as who are dedicated to this difficult work to continue to address this disease and improve living conditions in their communities. This manual does not include didactic techniques to build promotor/a skills in group facilitation, although we do provide examples of the techniques that we use. We recommend that the following pages be used in combination with many other complementary educational materials.

5. Please describe how your product or the project that resulted in the product builds on a relevant field, discipline or prior work. You may cite the literature and provide a bibliography in the next question if appropriate.

U.S.-Mexico border communities suffer devastating rates of diabetes and the farmworker population is among the most vulnerable. For those with diabetes, diet, physical activity, and glucose self-monitoring, are fundamental to avoiding long-term complications. However, the drastic lifestyle changes can be overwhelming both physically and emotionally and the social network to potentially support self-management is often not in place. Family members migrate to follow the harvest, children move to urban areas, and extended family live in Mexico. In attempting to manage their diabetes, elderly persons may become lonely and depressed as they experience increasing health problems. Numerous studies document positive correlations between social support and better diabetes management and specifically among Hispanics.

The overall objective of the Campesino Diabetes Management Program (CDMP) was to utilize the Promotor/a Model to improve social support for people with diabetes for self-management across the domains in which they interact, including peers, families, the community, the environment, and health care. Promotores/a, also known as health promoters, community health workers, community health advisors, and community health advocates, have been working with Latino populations in the Southwest for several decades. Promotores/as are well-respected, indigenous community members who seek to eliminate health problems by increasing healthcare utilization, providing health education, and advocating for patient needs. Program evaluations show that promotores/as have successfully increased health knowledge and/or health service utilization in many areas including nutrition diabetes, chronic disease screening, and cancer screening. Promotores/as can improve the cultural competence of health care and translate complex issues related to cultural interpretations of health. The Promotor/a model is an effective means to conduct outreach, deliver health information, and carry out case monitoring, especially within marginalized communities that encounter numerous barriers to health care access. Promotores/as are equally effective as nurse case managers, making them a suitable alternative in an environment of limited resources.

Our evaluation of CDMP sought to determine if CHW support is effective in improving diabetes self management and diabetes-related clinical outcomes among farmworkers in the community. Results demonstrated a 1% drop in HbA1C among high risk participants. Improvements were associated with promotora advocacy and participation in promotora-led support groups.

6. Please provide a bibliography for work cited above or in other parts of this application. Provide full references, in the order sited in the text (i.e. according to number order). .

1 Pan American Health Organization. Press release: Diabetes increasing along U.S.-Mexico Border – 2007. Available at: http://www.fep.paho.org/eng/TechnicalCooperation/Diabetes/SurveyResults /tabid/318/language/en-US/Default.aspx. Accessed September 3, 2008

2 California Institute for Rural Studies (2000) Suffering in silence: A report on the health of California’s agricultural workers. The California Endowment, Woodland Hills, CA.

3 Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med. 1993; 329:977–986.

4 Black, S. Increased health burden associated with concomitant depressive symptoms and diabetes in older Mexican Americans. Diabetes Care.1999: 22(1);56-64.

5 Gallant, MP. The influence of social support on chronic disease self-management: A review and directions for research. Health Education and Behavior. 2003: 30(2);170-195.

6 Gleeson-Kreig, J, Bernal, H, & Woolley, S. The role of social support in the self-management of diabetes mellitus among a Hispanic population. Public Health Nursing. 2002: 19(3);215-222.

7 Elder, J.P.; Ayala, G.X.; Campbell, N.R.; Slymen, D.; Lopez-Madurga, E.T.; Engelberg, M. (2005). Interpersonal and print nutrition communication for a Spanish-dominant Latino population: Secretos de la buena vida. Health Psychology, 24(1), 49-57.

8 Corkery, E.; Palmer, C.; Foley, M.E.; Schechter, C.B.; Frisher, L.; Roman, S.H. (1997). Effect of a bicultural community health worker on completion of diabetes education in a Hispanic population. Diabetes Care, 20(3), 254-257.

9 Ingram M, Gallegos G, Elenes J. Diabetes is a community issue: the critical elements of a successful outreach and education model on the U.S.-Mexico border. Preventing Chronic Disease [serial online] 2005 Jan. Available from: URL: http://www.cdc.gov/pcd/issues/2005/jan/04_0078.htm.

10 Hunter, J.; de Zapien, J.; Papenfuss, M.; Fernandez, M.; Meister, J.; Giuliano, A. (2004). The impact of a promotora on increasing routine chronic disease prevention among women aged 40 and older at the U.S.-Mexico border. Health Education & Behavior, 31(4 Suppl), 18S-28S.

11 Navarro, A.; Senn, K.; McNicholas, L.; Kaplan, R.; Roppe, B.; Campo, M. (1998). Por la vida model intervention enhances use of cancer screening tests among Latinas. American Journal of Preventive Medicine, 15(1), 32-41.

12 Hansen, L. K.; Feigl, P.; Modiano, M. R.; Lopez, J. A.; Escobedo Sluder, S.; Moinpour, C. M. (2005). An educational program to increase cervical and breast cancer screening in hispanic women: A southwest oncology group study. Canc er Nursing, 28(1), 47-53.

13 Howard, CA, Andrade, SJ, Byrd, T. The ethical dimensions of cultural competence in border health care settings. Family and Community Health. 2001: 23(4): 36-49.

14 Swider, SM. Outcome Effectiveness of Community Health Workers: An Integrative Literature Review. Public Health Nursing. 2002: 19(1);11-20.

15 Gary, T, Bone, LR, Hill, MN, Levine, DM, McGuire, M, Saudek, C, Brancati, FL. Randomized controlled trial of the effects of nurse case manager and community health worker interventions on risk factors for diabetes-related complications in urban African Americans. Preventive Medicine. 2003: 37;23-32.

16 Ingram, M, Torres, E, Redondo, F, Bradford, G, Wang, C and O’Toole, M. The impact of promotoras on social support and glycemic control. The Diabetes Educator. 2007:33(6):172S-178S.

7. Please describe the project or body of work from which the submitted product developed. Describe the ways that community and academic/institutional expertise contributed to the project. Pay particular attention to demonstrating the quality or rigor of the work:

• For research-related work, describe (if relevant) study aims, design, sample, measurement instruments, and analysis and interpretation. Discuss how you verified the accuracy of your data.
• For education-related work, describe (if relevant) any needs assessment conducted, learning objectives, educational strategies incorporated, and evaluation of learning.
• For other types of work, discuss how the project was developed and reasons for the methodological choices made.

Project: The Campesinos Diabetes Management Program (CDMP), created by Campesinos Sin Fronteras, a 501-C3 community-based organization committed to serving farmworkers, was initially one of eight demonstration projects funded by the Robert Wood Johnson Foundation Diabetes Initiative to build community support for diabetes self management. The rationale of CDMP was that community health workers, termed promotores/as in the Mexican American community, can effectively build social support among people with diabetes (la enfermedad) leading to improved self management behaviors and clinical outcomes. The collaboration and commitment of the Sunset Community Health Center (SCHC) was essential to CDMP. SCHC hired a promotora dedicated to diabetes patient care who handled cross referrals, conducted basic diabetes education, set up appointments for CDMP participants, and interacted with providers on patient issues. The Mel and Enid Zuckerman College of Public Health (MEZCOPH) collaborated with technical assistance in program development and participatory evaluation from the onset of the project.

Under the leadership of CSF, CDMP developed a community program to provide resources and support across the domains in which farmworkers interact, including peers, families, the community, the environment, and health care. As the CDMP promotoras began recruiting members of the farmworker community to the diabetes program, they became aware of the tremendous challenge they had undertaken. On one hand, the community was keenly conscious of the prevalence of diabetes; it seemed everyone had a family member with the disease. On another level, it was clear that people knew very little about how to prevent diabetes or control it. For example, people diagnosed with diabetes responded to vague dietary restrictions from their doctor by barely eating or no longer sharing meals with their families. Some chose not to tell their family members that they had been diagnosed with the disease. Many people with diabetes reported being isolated from their families, expressed a fatalistic attitude about their health, and experienced feelings of hopelessness and despair. Through experience, the core activity became weekly support groups facilitated by the promotoras. The objectives of the support groups were to provide information, build shared empathy, and create a network of support. Emotional support was a common theme of the groups, and based upon participant input, stress and depression became major topics. Informational aspects of social support were included in group sessions in which participants were taught and encouraged to set concrete and achievable self management goals. Advocacy was also a major component and addressed the tangible or practical aspects of social support such setting up doctor’s appointments and accessing health resources. The inclusion and discussion of spiritual and inspirational messages at the beginning of each group meeting was embraced by participants and became the foundation of the support group structure.

Evaluation: CDMP employed a participatory model of evaluation, in which three main project partners participated in the development and implementation of evaluation activities. A major advantage of participatory evaluation is that the evaluator is more familiar with the daily workings of the program and better able to identify evaluation measures that are meaningful and responsive to program partners. In the case of CDMP, the promotoras articulated that their priorities for the evaluation process, participated in developing the questionnaires and activity logs, and collected and managed the program data. CDMP used a number of different evaluation techniques, but the one relevant to this manual was a series of nine in-depth interviews conducted by the MEZCOPH evaluator with project staff from the two collaborating agencies. The purpose of the interviews was to gain a comprehensive picture of the program as it was actually delivered and to identify the key components of a promotor/a-driven diabetes self- management program. Although the actual questions were developed by the evaluator, they were based upon the expressed interest on the part of the promotoras to document the role of the promotor/a in promoting diabetes self management in a systematic way that would provide other promotor/a programs in both community and clinical settings with an insightful description of the variety and intensity of promotor/a activities.

8. Please describe the process of developing the product, including the ways that community and academic/institutional expertise were integrated in the development of this product.

In developing the proposal for the second phase of CDMP to Robert Wood Johnson, CSF and MEZCOPH stated our intention to develop a promotor/a manual, created by and for promotores/as, that would describe the program and share lessons learned in providing community support for diabetes self management. By this point, the CDMP promotoras had identified the influence of emotional health and the challenges their participants faced in accessing behavioral health services in this rural and marginalized farmworker community. We all felt that something new and significant was underway- for CSF as a champion of the promotor/a model, for the CDMP promotoras in seeing the impact of their efforts on the people they worked with, and for the MEZCOPH evaluator who felt an imperative to share the experience. The evaluator suggested using in-depth interviews as a way to explore the success and challenges of the program from different perspectives of program partners. We included the interviews as part of the evaluation methodology for the project proposal

Toward the end of the third program year, the evaluator completed in-depth interviews with all nine past and present promotoras involved in CDMP, the CSF Project Director and Executive Director, as well as the promotora and the medical director of SCHC. The evaluator used project objectives to develop the questions, but additionally decided to explore the concept of spirituality in diabetes self management because it had become an integral part of program activities. The evaluator received human subjects’ approval from the University of Arizona Institutional Review Board for the interview process, and all of the interviewees were consented. The interviews were 45 minutes to one hour long. With one exception, the interviews were conducted and analyzed in Spanish. The interviews were taped and transcribed in Spanish.

Analysis of the in-depth interviews was straightforward, given that the concepts under investigation were based upon CDMP objectives and were directly elicited by the questions. The evaluator used NVivo software to compile the data by question and then group responses by theme. This achieved a rudimentary analysis which: 1) masked the individual speakers within the compiled responses (who were the promotoras themselves) and 2) initiated the process of identifying common themes while leaving the data in a raw form that would allow the promotoras to be responsible for analyzing and interpreting the meaning.

The CSF Executive Director felt it was very important for the CDMP promotoras to take the lead in developing the manual that was to be directed to fellow community health workers. However, the promotoras had an overwhelming daily workload that made this activity challenging. Thus, the evaluator took on the role of coordinating development of the manual by setting up regular meetings with the promotoras to sustain the process. At the first meeting, the evaluator met with three promotoras, one of whom had been with the program since the beginning and another who had a major influence on formalizing the support group structure and integrating techniques that she had learned through her education in Mexico. At this meeting, the evaluator presented the promotoras with the compiled results of the interviews which provided a foundation for the formulation of an overall outline for the manual. The four launched into a routine in which: 1) the evaluator would provide the promotoras with compiled data from the interviews relevant to each section in the outline; 2) the promotoras would organize the information and integrate other experiences and information that they found relevant to form a first draft of the chapter; 3) the team would meet to go over the chapter and agree on some revisions; and 4) the evaluator would edit the chapter, which involved for the most part working on the flow of information and formatting. The process of developing a first draft lasted approximately 6 months.

The second stage of development has been more drawn out due to the competing demands on CSF to identify financial sources to continue their efforts in supporting diabetes self management, not to mention the overall responsibilities of running a non-profit grassroots agency. Over the course of a year, the CSF Executive Director and Program Director reviewed and edited the manual adding an overall introduction on the Promotor/a Model and underlying approach of the program. The MEZCOPH evaluator has played the role of cheerleader, urging CSF to finalize and disseminate this valuable product and contributing to the introductory section.

9. Please discuss the significance and impact of your product. In your response, discuss ways your product has added to existing knowledge and benefited the community; ways others may have utilized your product; and any relevant evaluation data about impact, if available. If the impact of the product is not yet known, discuss its potential significance.

Partners from CSF and MEZCOPH have been involved in the development and evaluation of promotor/a programs for more than 15 years and believe strongly in the effectiveness of the model and its foundation in community-based efforts. In 1998, we received a HRSA Rural Health Outreach Grant in collaboration with SCHC to increase access to quality and culturally competent diabetes services among farmworkers in South Yuma County. That project led to our ongoing collaborative efforts to address diabetes prevention and control and eventually the formulation of CDMP based at CSF.

Although the CDMP promotoras had been directly involved in diabetes patient education and support activities through the rural grant, their experience with CDMP made them aware of a complexity in self management behaviors they were unprepared for. Specifically, the number of people experiencing depression and the severity of their depression was overwhelming. When they tried to connect their participants with the behavioral health services, they were faced with further difficulty. Waiting times for initial appointments were long, those who had received services were dissatisfied with their cultural competence, and above all, the community stigmatized mental health issues making it difficult for their participants to ask for help. In the promotoras’ view, many of their clients were caught in a vicious cycle in which depression negatively impacted their capacity to manage their disease, which, as it grew out of control, was further debilitating to their mental health.

The promotoras found themselves faced with an urgent need to address mental health as a major factor in the quality of life of their clients. Recognizing that they were not licensed behavioral health providers, the promotoras attempted to make linkages with existing services and facilitate better and faster responses for their participants. Meanwhile, the support groups were evolving of their own accord into a safe environment for participants to express their emotions around the experience of having diabetes. Participants shared personal issues and crises with one another, resulting in a healing environment that encouraged all participants to practice better diabetes self-management. Personal testimonies and evaluation results demonstrated the positive impact of the program on emotional wellbeing, diabetes self management, and clinical outcomes.

We have not evaluated this manual, however, we have painstakingly evaluated the program on which it is based, the results of which are documented in The Diabetes Educator (cited above). Participants reported that they felt more comfortable talking about diabetes with their family and friends, as well as increased family support for diabetes self managements, HbA1C levels decreased 1% among high risk participants. Improved HbA1c was associated with promotor/a advocacy and participation in promotor/a-led support groups. With the help of RWJF we have disseminated the CDMP model through conferences and publications. In preparing those manuscripts we have reviewed available literature about diabetes self-management education and CHW programs. In the academic literature the focus on study design and clinical outcomes fails to include community-based efforts. In publications tailored to community needs there are efforts to describe the components of CHW programs and why they work, but these actually contain little concrete information about what it means to be a CHW and how to respond to the individual needs of community members. We feel that the lessons we learned can be of great service to other programs working with CHWs to address diabetes either in a clinical or grassroots setting. Furthermore, our attempt to speak directly to CHWs and their supervisors fills a gap that currently exists in the literature.

10. Please describe why you chose the presentation format you did.

The format of the manual evolved from the development process. We wanted the process to be relatively simple and direct so that the CDMP promotoras could be fully engaged. We also wanted the promotoras’ words and ideas to be directly transmitted to other CHWs, and thought that reading them on the page in their own language was of primary importance. Our hope is that by making this product available through a highly publicized and widely circulated source that it would reach more people working in their communities. This product was developed in Spanish and translated to English.

11. Please reflect on the strengths and limitations of your product. In what ways did community and academic/institutional collaborators provide feedback and how was such feedback used? Include relevant evaluation data about strengths and limitations if available.

The major strength of the Promotor/a Community Health Manual is that it benefits from being fully developed by promotores/as using information that has been compiled and organized in a systematic way. The process of reviewing the interview data broadened the promotoras’ perspective beyond their own experience and allowed them to identify the most important aspects of their work. In addition to providing other CHWs with a passionate, detailed and useful description of how they might approach their work, it also providers supervisors, who may not have a background as a CHW, with an orientation to the need for flexibility and innovation in responding to community needs. Furthermore, the integration of perspectives from our community health center partners makes the work relevant to clinic-based programs. We have been contacted by staff members from two clinics, one in Boston and one in Wisconsin, who were attempting to integrate CHWs into their diabetes programs and who would have benefited greatly from this manual had we been able to make it available in English.

A second strength is that the manual is a product of a successful community-campus partnership. All of the participants without hesitation feel that we mutually benefit from our relationship and the work we do together. From the academic perspective, it is a privilege to work with an organization that is so rooted in the community and so compassionate about social change. From a community perspective, the collaboration of an academic partner is invaluable in helping to access resources and take the work to the next level.

A major limitation of our project has been our inability to finalize the manual, disseminate it, and gain feedback from other programs that attempt to use it. Toward the end of the CDMP grant, we sought assistance from our funders who encouraged publication and dissemination, and they were supportive, but unsure how to move such a product forward. It made it more difficult that we developed our manual in Spanish, and so had to translate it into English before we could share it. Ideally, we would have finalized our product and disseminated it on a website and at conferences so that we could integrate feedback into this product. However, we do not think it is too late to modify this manual or create other products based on input from other communities.

12. Please describe ways that the project resulting in the product involved collaboration that embodied principles of mutual respect, shared work and shared credit. If different, describe ways that the product itself involved collaboration that embodied principles of mutual respect, shared work and shared credit. Have all collaborators on the product been notified of and approved submission of the product to CES4Health.info? If not, why not? Please indicate whether the project resulting in the product was approved by an Institutional Review Board (IRB) and/or community-based review mechanism, if applicable, and provide the name(s) of the IRB/mechanism.

In its ideal state, participatory evaluation is a collaborative process in which project staff and the evaluator are equally committed to the project, the evaluation process, and using evaluation data to make the project better. Actual achievement of a participatory process is stymied by factors such as staff turnover, botched data collection, an evaluation agenda that does not fit the needs of the project, and lack of time spent by the evaluator with the actual project. CDMP was perhaps our most successful experience of participatory evaluation for several reasons. First, the program grew out of an existing effort and we were fully collaborative in preparing the project proposal to the Robert Wood Johnson Foundation. Second, in the previous project the CDMP promotoras had collected huge notebooks of information that was never used because it was overwhelming and unorganized; we all saw CDMP as a opportunity to systematically collect information that would describe what we were doing that we already knew had been effective. Third, RWJF provided substantial support to our efforts, offering ongoing technical assistance and providing a space away from the office for us to meet and work together intensively every year. Fourth, and most important, the promotoras on this project were completely committed to their work, they created an remarkable program and carefully documented everything they did.

Allowing ourselves room for critical reflection brings in the question of shared work and shared credit. As Spanish-speakers, there was limited involvement of the promotoras in attending the RWJF meetings and discussing their work with other projects and CHWs. CSF requested that RWJF consider providing simultaneous translation but that did not occur. SCHC also did not choose to attend the annual meetings, and thus was unable to benefit from the clinic-based projects that were attempting to implement innovative programs. Thus, it was really the management of CSF and the academic partner that were responsible for and involved with publication and dissemination of the work being done by the promotoras including this manual Together, we have made numerous conference presentations describing the project and evaluation results and have published two peer-reviewed articles. The promotoras have also presented at binational conferences. We should give ourselves credit to the extent that we contributed in the area in which we are the most capable, and consistently notified and invited all project partners to the table.

It is in the creation of this manual that the promotoras have been in the driver’s seat. Their passion is in the manual, and through it they hope to share with CHWs in other communities and around the nation. SCHC participated in the interviews and in preparing peer reviewed publications, but given time constraints has not yet been notified of our submission to CES4.